Chapter 17: Document It: Progress Notes

Chapter 17: Document It: Progress Notes

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

1. These make up the “official” medical file, the formal medical record shared with other medical professionals, clients (upon written request), and/or in response to subpoenas. Third-party payers generally have detailed requirements for the content of these. What are they?
   1. Process notes
   2. Progress notes
   3. Psychotherapy notes
   4. Payment notes

ANS:         B

REF:          Two Different Animals: Progress Notes Versus Psychotherapy Notes (p. 606)

1. What detailed information are third-party payers looking for in progress notes?
   1. Personal content of a client’s life
   2. Details on the therapeutic conversation
   3. The frequency and duration of symptoms
   4. None of the above

ANS:         C

REF:          Progress Notes (p. 606-607)

1. The goal with progress notes is to maximize client privacy while simultaneously doing which of the following?
   1. Acknowledging the clients medical history
   2. Documenting competent treatment that conforms to professional standards of care
   3. Writing psychotherapy notes
   4. Talking to third-party individuals to get a more holistic view of the client

ANS:         B

REF:          Progress Notes (p. 606-607)

1. Which of the following is an exception to the general principle of using minimal client information in progress notes?
   1. When interviewing a child
   2. When stabilizing a crisis situations
   3. When meeting a family sent by the court
   4. When a client has an affair

ANS:         B

REF:          Progress Notes (p. 606-607)

1. Which of the following is NOT one of the common ingredients of progress notes appropriate for meeting HIPAA guidelines and third-party payers?
   1. Clients full name
   2. Date, time, and length of session
   3. Who attended the session
   4. Client’s progress, including improvement or worsening of symptoms

ANS:         A

REF:    Progress Notes (p. 607